Provider Demographics
NPI:1467494229
Name:JA MEDICAL CENTER PS
Entity Type:Organization
Organization Name:JA MEDICAL CENTER PS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JANE-FRANCES
Authorized Official - Middle Name:IFEOMA
Authorized Official - Last Name:AKPAMGBO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:509-299-2858
Mailing Address - Street 1:PO BOX 1175
Mailing Address - Street 2:
Mailing Address - City:MEDICAL LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99022-1175
Mailing Address - Country:US
Mailing Address - Phone:509-299-2858
Mailing Address - Fax:509-299-2868
Practice Address - Street 1:725 NORTH STANLEY STREET
Practice Address - Street 2:SUITE A
Practice Address - City:MEDICAL LAKE
Practice Address - State:WA
Practice Address - Zip Code:99022-8819
Practice Address - Country:US
Practice Address - Phone:509-299-2858
Practice Address - Fax:509-299-2868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00042028207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8858643Medicare PIN